Referral Process

Any member of the HOPES MDT can make referrals within the model. Additional referrals can be generated from the community inclusive of law enforcement, fire department, concerned citizens, local businesses, and other service providers. Referrals can be made via this form.

Engagement Process

The coordinated services include outreach and engagement from a harm reduction approach, developing rapport while identifying risks and needs. During the engagement phase, a comprehensive assessment will be completed by the active disciplines, inclusive of medical needs, psychosocial assessment, safety assessment, substance use disorder assessment (ASAM as needed), housing needs (Smart Path Coordinated Entry assessment) and other relevant areas of concern.

Each HOPES participant will be assigned a lead provider, based on the agency the individual is most identified with. For example, if an individual is concerned about a medical issue and willing to work with the Homeless Person’s Health Project, they would take the lead on coordinating the other services. All agency participants will coordinate service delivery to the individual based on need. To facilitate close coordination of services, the HOPES MDT will meet three times per week. (We are recommending a shared “Problem List” format to include areas of Physical Health, Behavioral Health – Mental Health & SUD, Housing, Benefits, Criminal Justice Issues, Social Services Issues.) Each Engagement Plan will be based on the identified needs on the Problem List and a Stages of Change Approach to move treatment intervention strategies forward.

Stabilization

Through the HOPES MDT, participants can be linked directly to stabilization services as part of the engagement process and/or as a link to ongoing services. Stabilization services are focused on a planned intervention to affect change in at least one of the engagement disciplines (physical health, mental health, substance use disorder, or homelessness.) Stabilization services include: